Singapore Med J 2017; 58(12): 685-689

Practice Integration & Lifelong Learning

doi: 10.11622/smedj.2017107

CMEArticle

Physical therapy in the management of frozen shoulder

Hui Bin Yvonne Chan1, BSc(Hons), Pek Ying Pua2, BPhty, MManipPhty, Choon How How1, MMed, FCFP

Lucy, a 53-year-old woman, visited you several times in the past year. She had an aching pain
on her shoulder and, lately, had increasing difficulty lifting her arm or reaching behind her
back. You previously gave her painkillers as treatment. However, due to her history of gastric
problems, you were keen to explore physical therapy as part of management.

WHAT IS FROZEN SHOULDER? HOW COMMON IS THIS IN MY

Frozen shoulder, also known as adhesive capsulitis, is
defined as “a condition of uncertain aetiology, characterised
by significant restriction of both active and passive shoulder
motion that occurs in the absence of a known intrinsic
shoulder disorder”.(1) Patients with frozen shoulder typically
experience insidious shoulder stiffness, severe pain that
usually worsens at night, and near-complete loss of passive
and active external rotation of the shoulder. (2) There are
typically no significant findings in the patient’s history, clinical
examination or radiographic evaluation to explain the loss of
motion or pain.
Frozen shoulder can be classified as primary or secondary.
Primary idiopathic frozen shoulder is often associated with
other diseases and conditions, such as diabetes mellitus, and
may be the first presentation of a diabetic patient.(3) Patients
with systemic diseases such as thyroid diseases (4,5) and
Parkinson’s disease(6) are at higher risk. Secondary adhesive
capsulitis can occur after shoulder injuries or immobilisation
(e.g. rotator cuff tendon tear, subacromial impingement,
biceps tenosynovitis and calcific tendonitis). These patients
develop pain from the shoulder pathology, leading to reduced
movement in that shoulder and thus developing frozen
shoulder.
Frozen shoulder often progresses in three stages: the freezing
(painful), frozen (adhesive) and thawing phases (Fig. 1). In the
freezing stage, which lasts about 2–9 months, there is a gradual
onset of diffuse, severe shoulder pain that typically worsens at
night. The pain will begin to subside during the frozen stage
with a characteristic progressive loss of glenohumeral flexion,
abduction, internal rotation and external rotation. This stage
can last for 4–12 months. During the thawing stage, the patient
experiences a gradual return of range of motion that takes about
5–26 months to complete.(7,8) Although adhesive capsulitis is
often self-limiting, usually resolving in 1–3 years,(9) it can persist,
presenting symptoms that are commonly mild; pain is the most
common complaint.(10,11)
PRACTICE?
Frozen shoulder is estimated to affect 2%–5% of the general
population,(12) and can be significantly painful and disabling. It
most commonly affects those in their fourth to sixth decades of
life, and more often occurs in women than in men.(8,13)
The term ‘frozen shoulder’ is often loosely used and wrongly
attributed to other shoulder limitations such as a rotator cuff
tear or osteoarthritis. Subacromial pathology (e.g. rotator cuff
tendinopathy, subacromial bursitis and impingement syndrome)
can closely resemble frozen shoulder in the early stages as well.(7)
For appropriate management, it is important for physicians to
ascertain the diagnosis. As the physical therapy described in this
article is specifically targeted at adhesive capsulitis, techniques
for other shoulder conditions require further customisation.
WHAT CAN I DO IN MY PRACTICE?
Most frozen shoulder cases can be managed in the primary care
setting. Clinicians are encouraged to start the treatment with
patient education. Explaining the natural history of the condition
often helps to reduce frustration, increase compliance and allay
fears for the patient. It is also advisable to acknowledge that full
range of motion may never be restored. Common conservative
treatments for frozen shoulder include nonsteroidal anti-
inflammatory drugs (NSAIDs), glucocorticoids given orally or
as intra-articular injections, and/or physical therapy.(14) Many
practitioners, however, find themselves limited to prescribing
medications to relieve pain and inflammation.
Many physical therapy and home exercises can be used as a
first-line treatment for adhesive capsulitis.(12) Physical therapy has
been shown to bring about pain relief and return of functional
motion.(15) When used in combination with physical therapy,
NSAIDs were proven to be more effective as compared to using
NSAIDs alone.(16) Similarly, various studies on intra-articular
corticosteroids used in combination with physiotherapy resulted
in better outcomes compared to intra-articular corticosteroids
alone.(17,18)

Care and Health Integration, 2Rehabilitative Services, Changi General Hospital, Singapore
1

Correspondence: Ms Yvonne Chan Hui Bin, Executive, Care and Health Integration, Changi General Hospital, 2 Simei Street 3, Singapore 529889. yvonne_chan@cgh.com.sg

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Table I. A summary of the three phases of frozen shoulder.

Freezing Frozen Thawing

Duration
Signs and symptoms
Conservative treatment
Physical therapy at each
stage
2–9 mth
Gradual onset of diffuse, severe
shoulder pain that worsens at night
• Patient education
• Medications: nonsteroidal anti‑inflammatory drugs, oral or intra-articular glucocorticoids
• Physical therapy
• Gentle stretching exercises
• Modalities: heat/ice pack
4–12 mth
Pain begins to subside but there is
a characteristic progressive loss of
range in motion
• Maintain stretching exercises
• Strengthening exercises:
isometric/static
• Modalities: heat/ice pack
5–26 mth
Gradual return of range of
motion
•M  aintain stretching
exercises
• Strengthening exercises that
progress from isometric/
static to resistance‑based

or circular motion. Patients can also try pulley exercises, as

Movement tolerated, and neck or scapular muscle releases. It is important not
Severity

to aggravate a frozen shoulder, as aggressive stretching beyond

the pain threshold can result in inferior outcomes, particularly in
the early phase of the condition.(21) There has also been evidence
that patients should avoid a forward shoulder posture as it may
Freezing Frozen Thawing cause a loss of glenohumeral flexion and abduction.(22)

Pain
Time
Fig. 1 Chart shows the clinical presentation of frozen shoulder. Icons with
facial expressions represent the level of pain of the patient.
The physical therapy for primary idiopathic frozen shoulder
described herein can be useful for prescribing home exercises
to increase shoulder mobility. Nevertheless, it is imperative to
consider the patient’s symptoms and stage of the condition when
selecting a physical treatment method for frozen shoulder. Table I
summarises the key features of each stage.
Freezing phase
Pain is often most severe during the freezing phase and patients in
this phase would benefit from learning pain-relieving techniques.
These exercises include gentle shoulder mobilisation exercises
within the tolerated range (e.g. pendulum exercise, passive supine
forward elevation, passive external rotation, and active assisted
range of motion in extension, horizontal adduction, and internal
rotation). A heat or ice pack can be applied as a modality to relieve
pain before the start of these exercises. The application of moist
heat in conjunction with stretching has been shown to improve
muscle extensibility.(19) Certain patients might also find it useful
to take analgesics before physical therapy.
Patients should begin with short-duration (1–5 seconds) range
of motion exercises, which should be in a relatively pain-free
range.(20) Fig. 2 shows three commonly performed stretching
exercises that are particularly useful for patients in this painful
stage. Pendulum exercises can be used in flexion or abduction
Frozen phase
Similar to the freezing phase, a heat or ice pack can be applied
during the frozen phase to relieve pain before commencing
exercises. Home exercises such as those in Fig. 2 can be continued
within the tolerated limit. In particular, stretching exercises
for the chest muscles and muscles at the back of the shoulder
should be maintained. Rotation before elevation exercises, such
as an external rotation stretch, are also recommended to avoid
increasing pain and inflammation.(22) At this stage, strengthening
exercises are added to maintain muscle strength. Isometric or static
contractions are exercises that require no joint movement and can
be done without worrying about increasing pain in the shoulder.
Fig. 3 shows strengthening exercises that can be performed
at home. The scapular retraction exercises gently stretch the
chest muscles and serve as basic strengthening for the scapular
muscles. Isometric shoulder external rotation can also be used
for flexion or abduction, within the available range, but care
should still be taken to avoid introducing aggressive exercises, as
overenthusiastic treatment could aggravate the capsular synovitis
and subsequently cause pain.
Thawing phase
In the thawing phase, the patient experiences a gradual return
of range of motion. It is crucial to get the shoulder back to
normal as quickly as possible by regaining full movement and
strength. Strengthening exercises are important, as the shoulder
is considerably weakened after a few months of little movement.
Compared to the frozen phase, the patient can perform more
mobility exercises and stretches (e.g. Figs. 2 & 3) with a longer
holding duration, within tolerated boundaries. Strengthening
exercises can also progress from isometric or static contractions,
to exercises using a resistance band, and eventually to free weights

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Practice Integration & Lifelong Learning

2a 2b

2c 2d

Fig. 2 Photographs show examples of stretching exercises: (a) active assisted shoulder forward flexion with wand; (b) active assisted shoulder external
rotation with wand; and (c & d) pendulum exercise.

3a 3b 3c

Fig. 3 Photographs show examples of strengthening exercises: (a) scapular retraction; (b) posterior capsule stretch; and (c) isometric shoulder external
rotation. In scapular retraction, the scapulae are pulled towards each other (arrows in a).

or weight machines. Rotator cuff exercises, as well as posture
exercises and exercises for the deltoid and chest muscles, can
be included in the treatment as well.
Referral
Referral to a physiotherapist can be made when the physician
thinks that the patient’s condition needs more guidance and
can benefit from a physiotherapist review, or when the patient’s
condition fails to improve after trialling exercises such as the
above. Referral to an orthopaedics specialist may be necessary
if some investigations are needed, such as radiography of the
shoulder (to look for calcific tendonitis or acromial bone spur,
i.e. a Type 3 Bigliani spur) and magnetic resonance imaging of
the shoulder to rule out cuff tear.
Manipulation of the frozen shoulder under regional
anaesthesia together with intra-articular glenohumeral joint

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cortisone injection is an effective form of treatment in frozen
shoulder without cuff tear. This is especially so if the patient would
like a rapid improvement in symptoms and avoid the expected
natural history of pain, stiffness and slow gradual thawing of the
stiff shoulder.
Lucy started on strengthening exercises at home,
following your instructions. On her next visit to your
clinic, she was happy to report that these exercises had
relieved some of her pain and improved her shoulder
movement. You assured her that her condition usually
takes time to recover and instructed her to progress
to resistance-based exercises. You noted that she
was on track to recovery and did not refer her to a
physiotherapist.
ABSTRACT Frozen shoulder, also known as adhesive
capsulitis, is a common presentation in the primary care
setting and can be significantly painful and disabling. The
condition progresses in three stages: freezing (painful),
frozen (adhesive) and thawing, and is often self-limiting.
Common conservative treatments include nonsteroidal
anti-inflammatory drugs, oral glucocorticoids, intra-
articular glucocorticoid injections and/or physical
therapy. However, many physicians may find themselves
limited to prescribing medications for treatment. This
article elaborates on physical therapy exercises targeted
at adhesive capsulitis, which can be used in combination
with common analgesics.
Keywords: adhesive capsulitis, frozen shoulder, physical therapy, self-management
TAKE HOME MESSAGES
1. Patients with frozen shoulder typically experience insidious
shoulder stiffness and near-complete loss of passive and
active external rotation of the shoulder.
2. Frozen shoulder occurs in three phases: freezing (painful),
frozen (adhesive) and thawing, and is often self-limiting.
3. Common conservative treatments for frozen shoulder
include NSAIDs, glucocorticoids given orally or as intra-
articular injections, and/or physical therapy.
4. Physical therapy and home exercises can be a first-line
treatment for frozen shoulder, with consideration of the
patient’s symptoms and stage of the condition.
5. In the freezing (painful) stage, gentle stretching exercises
can be done but should be kept within a short duration
(1–5 seconds) and not go beyond the patient’s pain
threshold.
6. In the frozen (adhesive) stage, strengthening exercises
such as scapular retraction, posterior capsule stretch and
isometric shoulder external rotation can be added to the
patient’s exercises for maintenance of muscle strength.
7. In the thawing stage, the patient experiences a gradual
return of range of motion; both stretching and strengthening
exercises can increase in intensity, with a longer holding
duration.
ACKNOWLEDGEMENT
Figs. 2 and 3 are reproduced with permission of Changi General
Hospital, Singapore.
REFERENCES
1. Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J Shoulder
Elbow Surg 2011; 20:322-5.
2. Brue S, Valentin A, Forssblad M, Werner S, Mikkelsen C, Cerulli G. Idiopathic
adhesive capsulitis of the shoulder: a review. Knee Surg Sports Traumatol
Arthrosc 2007; 15:1048-54.
3. Pal B, Anderson J, Dick WC, Griffiths ID. Limitation of joint mobility and
shoulder capsulitis in insulin- and non-insulin-dependent diabetes mellitus. Br
J Rheumatol 1986; 25:147-51.
4. Cakir M, Samanci N, Balci N, Balci MK. Musculoskeletal manifestations in
patients with thyroid disease. Clin Endocrinol (Oxf) 2003; 59:162-7.
5. Wohlgethan JR. Frozen shoulder in hyperthyroidism. Arthritis Rheum 1987;
30:936-9.
6. Riley D, Lang AE, Blair RD, Birnbaum A, Reid B. Frozen shoulder and other
shoulder disturbances in Parkinson’s disease. J Neurol Neurosurg Psychiatry
1989; 52:63-6.
7. Prestgaard TA. Frozen shoulder (adhesive capsulitis). In: UpToDate [online].
Available at: https://www.uptodate.com/contents/frozen-shoulder-adhesive-
capsulitis. Accessed November 1, 2017.
8. Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ 2005; 331:1453-6.
9. Maund E, Craig D, Suekarran S, et al. Management of frozen shoulder: a systematic
review and cost-effectiveness analysis. Health Technol Assess 2012; 16:1-264.
10. Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder.
J Shoulder Elbow Surg 2008; 17:231-6.
11. Vastamäki H, Kettunen J, Vastamäki M. The natural history of idiopathic
frozen shoulder: a 2- to 27-year followup study. Clin Orthop Relat Res 2012;
470:1133-43.
12. Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA. Current review of adhesive
capsulitis. J Shoulder Elbow Surg 2011; 20:502-14.
13. Rizk TE, Pinals RS. Frozen shoulder. Semin Arthritis Rheum 1982; 11:440-52.
14. Wong PL, Tan HC. A review on frozen shoulder. Singapore Med J 2010; 51:694-7.
15. Page P, Labbe A. Adhesive capsulitis: use the evidence to integrate your
interventions. N Am J Sports Phys Ther 2010; 5:266-73.
16. Dudkiewicz I, Oran A, Salai M, Palti R, Pritsch M. Idiopathic adhesive capsulitis:
long-term results of conservative treatment. Isr Med Assoc J 2004; 6:524-6.
17. Page MJ, Green S, Kramer S, et al. Electrotherapy modalities for adhesive
capsulitis (frozen shoulder). Cochrane Database Syst Rev 2014; (10):CD011324.
18. Mobini M, Kashi Z, Bahar A, Yaghubi M. Comparison of corticosteroid injections,
physiotherapy, and combination therapy in treatment of frozen shoulder. Pak
J Med Sci 2012; 28:648-51.
19. Järvinen TA, Järvinen TL, Kääriäinen M, Kalimo H, Järvinen M. Muscle injuries:
biology and treatment. Am J Sports Med 2005; 33:745-64.
20. Kelley MJ, McClure PW, Leggin BG. Frozen shoulder: evidence and a proposed
model guiding rehabilitation. J Orthop Sport Phys Ther 2009; 39:135-48.
21. Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: a prospective
study of supervised neglect versus intensive physical therapy in seventy-seven
patients with frozen shoulder syndrome followed up for two years. J Shoulder
Elbow Surg 2004; 13:499-502.
22. Donatelli R, Ruivo RM, Thurner M, Ibrahim MI. New concepts in restoring
shoulder elevation in a stiff and painful shoulder patient. Phys Ther Sport 2014;
15:3-14.
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SINGAPORE MEDICAL COUNCIL CATEGORY 3B CME PROGRAMME

(Code SMJ 201712A)
 True  False
1. Frozen shoulder is defined as a condition of uncertain aetiology, characterised by significant restriction of   □    □
both active and passive shoulder motion occurring in the absence of a known intrinsic shoulder disorder.
2. Patients with frozen shoulder typically experience severe pain, which is worse in the day and improves at night.   □    □
3. There is higher risk of primary idiopathic frozen shoulder in patients with diabetes mellitus, and it may   □    □
be the first presentation of a diabetic.
4. Adhesive capsulitis can occur after shoulder injuries or immobilisation (e.g. trauma, rotator cuff tear   □    □
or shoulder surgery) or with systemic diseases such as thyroid diseases and Parkinson’s disease.
5. Frozen shoulder often progresses in two stages: the freezing (painful) and thawing phases.   □    □
6. In the freezing stage, which lasts about 1–2 months, there is a gradual onset of diffuse, severe shoulder   □    □
pain that typically worsens at night.
7. During the thawing stage, the patient experiences a gradual return of range of motion, which takes   □    □
about 5–26 months to complete.
8. Adhesive capsulitis is often self-limiting, usually resolving in 1–3 years without professional treatment.   □    □
9. Frozen shoulder is estimated to affect about 2–5 in 100 persons among the general population, and   □    □
can be significantly painful and disabling.
10. Frozen shoulder most commonly occurs in those in their sixth to eighth decades of life, and more   □    □
often in women than men.
11. There are limited management modalities for frozen shoulder in the primary care setting, and these are   □    □
limited to patient education of its natural history and appropriate anti-inflammatory drugs and analgesia.
12. Doctors should be encouraging and reassure patients that they will definitely regain full range of   □    □
motion with adequate thawing time.
13. Physical therapy has been shown to increase pain for patients but can speed up the return of functional   □    □
motion.
14. Pain is often most severe during the freezing phase, and there are no physical therapies targeted at   □    □
pain relief.
15. A heat or ice pack can be applied as a modality to relieve pain before the start of physical therapy exercises.   □    □
16. Aggressive stretching beyond the pain threshold can result in faster recovery and better outcomes,   □    □
particularly in the early phase of the condition.
17. Strengthening exercises are added at the frozen stage to maintain muscle strength.   □    □
18. In the thawing phase, it is crucial to get the shoulder back to normal as quickly as possible by regaining   □    □
full movement and strength. Strengthening exercises are important, as the shoulder is considerably
weakened after a few months of little movement.
19. Referral to a physiotherapist can be made if the patient needs more guidance or fails to improve after   □    □
the recommended trial of exercises.
20. Patients with calcific tendonitis or acromial bone spur seen on shoulder radiographs need to be referred   □    □
to an orthopaedics specialist for further evaluation and treatment.

Doctor’s particulars:
Name in full:___________________________________________  MCR no.:�����������������������������������������������
Specialty: ______________________________________________ Email:��������������������������������������������������

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